TRUST POLICY FOR EMERGENCY PLANNING Reference Number: CL-OP/ 2013/027 Version: 1.4 Status: New Draft Author: Ashley Reed Job Title: Head of Security and EPO Version / Amendment History Version Date Author Reason 1 Dec 2009 Ashley Reed New 1.2 Dec 2009 Amended following feedback from circulation list 1.3 Dec 2009 Pam Twine Reformatted 1.4 March 2013 Intended Recipients: All Trust staff Ashley Reed Review Training and Dissemination: Launched through Intranet. Emergency Incident Training. Articles in Synapse and Signpost. To be read in conjunction with: Trust Policy & Procedure for Maintaining a Safe Environment (incorporating the Management of Threatening Behaviours in the Workplace). Trust Policy for Assessment and Management of Risk, Trust Major Incident Plan sdaht_009893, Trust Business Continuity Plan, In consultation with and Date: Emergency Planning Steering Group, Resilience Group, Risk Committee EIRA stage one Completed Yes Stage two N/A Procedural Documentation Review Group Assurance and Date Approving Body and Date Approved October 2013 Amendments approved by PDRG on behalf of ME Date of Issue November 2013 Review Date and Frequency Contact for Review October 2016 (then every 3 years) Head of Security and Emergency Planning Officer 1
Executive Lead Signature Chief Operating Officer Approving Executive Signature Chief Executive 2
Contents Section Page 1 Introduction 4 2 Purpose and Objectives 4 3 Definitions Used 5 4 Key Responsibilities/Duties 6 4.1 Chief Executive and Trust Board 6 4.2 Chief Operating Officer 6 4.3 Deputy Chief Operating Officer 6 4.4 Divisional Directors and General Managers 6 4.5 Emergency Planning Officer 7 5 Resilience Management 8 5.1 Assessment of Risks to the Trust 8 5.2 Business Continuity Management System 8 5.3 Major Incident/Emergency Plans 9 5.4 Co-operation and Sharing Information 9 5.5 Warning and Informing 9 5.6 Emergency Planning Structure 10 5.6.1 Emergency Planning Steering Group 10 5.6.2 Resilience Group 10 5.6.3 Pandemic Influenza Governance Structure 11 5.7 Response to a Disruption to Business Continuity and an Emergency 6 Monitoring Compliance and Effectiveness 11 7 References 13 Appendix 8 Consultation and Approval Matrix 14 Appendix 9 Checklist for the Review and Approval of Procedural Document Appendix 9 Continued 16 11 15 3
TRUST POLICY FOR EMERGENCY PLANNING 1 Introduction Under the Civil Contingencies Act of 2004, Derby Hospitals NHS Foundation Trust is classified as a Category 1 responder. The Trust is required under the Act to maintain plans to ensure that the Trust can respond to events which disrupt business continuity and to ensure that in the event of a major incident or emergency, if called upon, it can deliver an effective and co-ordinated response to the major incident. 2 Purpose and Outcome The purpose of this Policy is: That as a Category 1 responder the Trust can provide a coordinated response to a disruption to business continuity or to a major incident. The objective of this Policy is to ensure: That emergency planning roles and responsibilities of the Trust are defined; That plans are prepared and maintained in order to respond to a major incident or emergency; A comprehensive business continuity management system is established and maintained in line with the British Standard for Business Continuity Planning (BS NHS 25999); The reputation of the Trust is not compromised; The importance of business continuity planning and the maintenance of service provision is embedded into the Trust; The risk of emergencies occurring is assessed and use to inform major incident and business continuity planning; Plans are put in place so as to maintain or recover services in the event of a disruption to business continuity; Arrangements are in place to warn and inform and advise the public in the event of an emergency or Major Incident; Plans are subject to ongoing exercising and revision; and that The Trust shares information with other responders to enhance coordination and co-operate with other local responders. 4
3 Definitions Used Emergency or Major Incident: Business Continuity Plan: Major Incident Plan: Pandemic Influenza Plan Resilience Category 1 Responders Category 2 Responders LRF Health Emergency Planning Forum Risk Assessment Working Group Defined under the Civil Contingencies Act as an event or a situation which threatens serious damage to human welfare in a place in the UK, or war or terrorism which threatens serious damage to the security of the UK. Special arrangements within an NHS organisation to maintain or restore services following a disruption to business continuity Plans for implementation of special measures for the reception, assessment and treatment of patients involved in an emergency. Plans for implementation of special measures to prepare for and manage any future pandemic influenza outbreaks. Ability to adapt and respond to disruptions to normal business continuity. Organisations that under the Civil Contingencies Act 2004 are required to comply with the full emergency planning responsibilities. Organisations that under the Civil Contingencies Act 2004 are required to provide information to Category 1 Responders. The principal mechanism for multi-agency co-operation between Category 1 and Category 2 Responders. All NHS Trusts in Derbyshire are members of the Local Resilience Forum, although the health community is represented by Derbyshire Cluster PCT. A sub-group of the Local Resilience Forum, this is the main forum for all health trusts in Derbyshire to discuss emergency planning matters A sub-group of the Local Resilience Forum, this group assesses the hazards in Derbyshire, identifying the main risks to business continuity and causes of major incidents. The group has assessed the hazards within Derbyshire, which have been collated in a Community Risk Register which is available from the Derbyshire Prepared website. 5
4 Key Responsibilities/Duties 4.1 Chief Executive and Trust Board The Chief Executive and Trust Board will ensure that: There is a Trust Major Incident Plan which is regularly reviewed, updated and tested in line with National Guidance. There will be clearly defined board level responsibility for the Trust s critical assets, with clear lines of accountability for access and egress throughout the Trust. 4.2 Chief Operating Officer The Chief Operating Officer will: Ensure that the Trust meets the requirements of emergency planning legislation and guidance, specifically with regards to the Civil Contingencies Act 2004 and NHS Emergency Planning Guidance 2005. Provide regular reports to the Chief Executive and Board regarding emergency planning. Ensure that the Deputy Chief Operating Officer and Emergency Planning Officer have sufficient resources available for the Trust to effectively fulfil its emergency planning responsibilities. 4.3 Deputy Chief Operating Officer The Deputy Chief Operating Officer will: Drive the Trust s emergency planning strategy as chair of the Emergency Planning Steering Group. Chair the Trust s Resilience Group. Ensure that there are effective and tested business continuity and major incident, and pandemic influenza plans in place. 4.4 Divisional Directors & General Managers Divisional Directors & General Managers will: Ensure that their departments have up to date Business Impact Analysis and robust business continuity recovery plans in place and where relevant, major incident plans and action cards. Ensure their staff follows the direction of the Trust s Command and Control Team and Operations Team in the event of a major Incident. 6
Ensure that their staff follow the direction of the Service Interruption Management Team in the event of a disruption to business continuity. Carry out all local risk assessments including a consideration of implications for business continuity. Update and review their plans annually. Ensure that all relevant staff are trained in their roles and have received training in the use of major incident action cards and business continuity plans. 4.5 Emergency Planning Officer The Emergency Planning Officer will: Chair the Facilities Management Emergency Planning Sub Group Deputise for the Deputy Chief Operating Officer as chair to the Resilience Group; Provide support to the Deputy Chief Operating Officer in order that the Trust s emergency planning obligations can be met, Ensuring that the Trust is prepared for and can respond to a disruption to service provision in order that it can maintain business continuity. 7
5. Resilience Management The Civil Contingencies Act 2004 and the NHS Emergency Planning Guidance 2005 requires the Trust to:- Assess the risk of emergencies occurring; Establish business continuity management arrangements; Develop major incident / emergency plans; Share information with and co-ordinate emergency planning with partner agencies; and Have arrangements in place to warn, inform and advise the public about emergency planning matters and in the event of a major incident 5.1 Assessment of risks to the Trust Through the work of the LRF and specifically the LRF s Risk Assessment Working Group, the Trust is made aware of new and emerging risks to business continuity and those that may cause a major incident or emergency. The risks to business continuity can be from the external environment (for example, power failures, severe weather) or from within an organisation (for example, utility failures, loss of key staff). The Trust uses this information in preparing plans and considering the implications of the risks for the Trust. 5.2 Business Continuity Management System Business continuity management is the process by which an organisation ensures that it can maintain or recovery service provision in the event of a disruption. These requirements are met through the implementation of a business continuity plan which will aim to protect and sustain the Trust s capacity to maintain its critical services if they are threatened by a disruption, either internally or externally. This would include maintaining the ability to mount a major incident response. Departmental Business Impact Analysis assesses the priority of services to ensure that the Trust has determined the critical services. A service level business continuity plan pulls together the response of a Service Delivery Unit / Department to an incident. The components and content of a service level business continuity plan will vary from Service Delivery Unit / Department to Service Delivery Unit / Department and will have a different level of detail based on the essential functions identified. 8
5.3 Major Incident / Emergency Plans As a major incident or emergency affecting the community could be caused by a variety of hazards, the intention of the Major Incident Plan is to ensure that the Trust can implement a flexible response to the Major Incident. Specific planning has been undertaken in relation to receiving patients who may have been exposed to a hazardous substance as a result of an accident or malicious act. A separate Chemical, Biological, Radiological and Nuclear (CBRN) Plan has been prepared which outlines the actions to follow if the hospital receives contaminated patients. 5.4 Cooperation and Sharing Information Within Derbyshire the principal mechanism for co-operation between the responders is through the county s Local Resilience Forum. However, the Trust recognises that at the local level working in collaboration with partner agencies, including the sharing of relevant information is important to ensure that any response to an emergency is effective and well co-ordinated. 5.5 Warning and Informing Category 1 responders must have arrangements to warn the public if an emergency is likely to occur or to provide information and advice following an emergency or Major Incident. The Trust will work closely with partner agencies through the Local Resilience Forum s Warning and Informing Group in order to meet this requirement. The Trust s Communication Team will co-ordinate with health communication teams and partner agencies to ensure the communication response is consistent and effective. 9
5.6 Emergency Planning Structure Risk Committee Emergency Planning Steering Group Resilience Sub-Group 5.6.1 Emergency Planning Steering Group This Group will ensure the implementation and maintenance of planned arrangements in line with statutory requirements and appropriate guidance, to facilitate an effective response to an emergency and / or disruption to business continuity/and or pandemic influenza outbreak, whether as a result of an unplanned external or internal incident. The chair of the group will regularly report to the Risk Committee on the Trust s emergency planning preparedness. 5.6.2 Resilience Group This sub group will ensure that the Trust implements and maintains a Major Incident Plan, in line with statutory requirements and appropriate guidance, to facilitate an effective response to an emergency or major incident. The Trust is responsible for producing and maintaining major incident action cards for key roles and functions to be performed in the event that a major incident is declared. Key departments are responsible for producing and maintaining departmental specific major incident action cards. This sub group will also ensure that the Trust anticipates the risks to service provision and that business continuity plans are in place to minimise disruption when unplanned internal or external events significantly interrupt normal business. 10
5.6.3 Pandemic Influenza Governance Structure This set of virtual groups will come together to plan, implement and evaluate any future pandemic influenza threat. The virtual governance structure will be operationally established by the Emergency Planning Steering Group as and when required. Flu Cabinet Reports to Delivery Group Clinical Advisory Group Reports to Flu Cabinet Flu Management Team Reports to Flu Cabinet 5.7 Response to a Disruption to Business Continuity and an Emergency The Trust s response to a disruption to Business Continuity is based in the implementation of the Trust s Business Continuity Plan and local departmental plans. The decision to implement the Business Continuity Plan will depend on the scale of the disruption as the first course of action is for local managers to manage the disruption. However, when an event or incident is disrupting critical services or the disruption is wide spread then it may be necessary to implement the Business Continuity Plan. The Trust s response to an emergency is based on the Trusts Major Incident Plan which outlines how the Trust would implement special measures for the reception, assessment and treatment of patients involved in an emergency. The decision to declare a major incident by the Trust or Ambulance Service will depend on the nature and scale of the incident and whether the Trust is required to provide a response to the incident. 6 Monitoring Compliance and Effectiveness A regular test of the business continuity and MAJOR INCIDENT plans will be necessary to ensure that they are fit for purpose. The Emergency Planning Steering Group will adopt an annual programme of exercises, so that in line with the requirements of the Civil Contingencies Act 2004 and the NHS Emergency Planning Guidance 2005, the Trust as a minimum will undertake:- 11
A live exercise every three years; An annual table-top exercise; and Carry out a test of the communication cascade / call out every six months The business continuity and MAJOR INCIDENT plans as a minimum will be reviewed on an annual basis by the authors. A necessity for further reviews of the plans will also be undertaken in the event of:- Any changes to Trust services; As a result of lessons learnt from an incident; or Due to the implementation of new legislation or guidance. Paper copies of the plans will be located in the following areas:- The individual departments. The Operations Centre. It is the author s responsibility to ensure that the paper copies are kept updated. Electronic copies of the plans will be located on the Trust Intranet. The Emergency Planning Steering Group will adopt an annual programme of audits to ensure that the MAJOR INCIDENT and business continuity plans conform to planned arrangements. 6 monthly reports will be submitted to the Quality Assurance Committee by the Emergency Planning Steering Group. 12
7 References HM Government (2004); Civil contingencies Act 2004 HM Government (2005); Emergency Preparedness, Guidance on Part 1 of the Civil Contingency Act 2004, its associated Regulations and non-statutory arrangements HM Government (2005); Emergency Response and Recovery, Nonstatutory guidance to complete Emergency Preparedness Department of Health (2005); NHS Emergency Planning Guidance 2013 Department of Health (2007); Strategic Command Arrangements for the NHS during a Major Incident Department of Health (2007); Mass Casualties Incidents A Framework for Planning NHS East Midlands (2011); East Midlands Mass Casualties Framework NHS Guidance: Mass Casualties Incidents A Framework for Planning, NHS Guidance: Strategic Command Arrangements for the NHS during a Major Incident, Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (registration) Regulations 2009, Department of Health sponsored Publicly Available Specification (PAS) 2015:2010 Framework for health services resilience, NHS East Midlands: East Midlands Mass Casualties Framework 13
Appendix 8 Consultation and Approval Matrix Type of Document Human Resources Clinical Risk Management (inc Health & Safety) Consider Consultation With Education, Training & Development Trust Joint Council Trust Partnership Board JPAG MAC Senior Materons D&T Ethics PEG Medicines Management Health & Safety Committee JPAG MAC Approval (Content) Human Resources & Workforce Clinical Effectiveness Strategic Risk & Business Continuity Group Assurance (Process) Procedural Document Review Group Procedural Document Review Group Procedural Document Review Group Records Management IT Finance Nominated Manager Information Governance Health Informatics Strategic Board Health Records Strategy Group Health Informatics Strategy Group Senior Clinicians User Group Capex TMT FRAC Trust Board Dependent on the nature of the document. Approving Committee will be indicated in document application form. Dependent on the nature of the document. Approving Committee will be indicated in document application form Dependent on the nature of the document. Approving Committee will be indicated in document application form Procedural Document Review Group Procedural Document Review Group Procedural Document Review Group 14
Appendix 9 Checklist for the Review and Approval of Procedural Document 1. Title Title of document being reviewed: Is the title clear and unambiguous? Is it clear whether the document is a policy, procedure or strategy 2. Dissemination and Training Does the plan include the necessary training/support to ensure compliance? Does the plan identify how Trust staff informed about the new document? 3. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? 4. Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? 5. Approval Have the appropriate groups/committees been part of the consultation process Does the document identify that the Trust Procedural Document Review Group will approve it? 6. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? Are reasons for development of the document stated? Are the people involved in the development identified? Has relevant expertise been used? Yes/No/ Unsure Comments 15
Title of document being reviewed: Is there evidence of consultation with stakeholders and users? Yes/No/ Unsure Comments 7. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references and supporting documents cited? Are the references cited in full? 8. Document Control Does the document control reflect the process to date? Have archiving arrangements for superseded documents been addressed? 9. Process to Monitor Compliance and Effectiveness Are there KPIs or audit, reporting frameworks to support the monitoring of compliance with and effectiveness of the document? The has approved this Title: Name of Chair Date Signature The Trust Procedural Document Review Group has assured this Title: Name of Chair Date Signature 16